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E2. Epidemiology Lecture Notes
E2. Epidemiology Lecture Notes
E2. Epidemiology Lecture Notes
1
1. Introduction to Epidemiology
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Objectives
• After completing this chapter, you will be
able to
• Define Epidemiology and describe its components
• Distinguish between analytic and descriptive
Epidemiology
• Understand history and scope of Epidemiology
• Describe basic assumptions and uses of
Epidemiology
3
Definitions
4
Definitions…
Public health
5
Definitions
The word epidemiology is derived from three
Greek words:
Epi = Upon
Demo = people
Logy = study
Epidemiology is the study of that which falls upon
people
6
Definitions…
Epidemiology
7
Components of the definition
Epidemiology is a science
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Components…
10
Components…
12
Components…
5. Diseases & other health related events
Epidemiology is not only the study of diseases
The focus of Epidemiology are not only patients
It studies all health related conditions
Injuries and accidents, Vital events, health related
behavior (smoking, unsafe sex, etc.)
Epidemiology is a broader science
13
Components…
6. Human population
Epidemiology diagnoses and treats
communities/populations
Clinical medicine diagnoses and treats patients
Epidemiology is a basic science of public health
Group Discussion
1.What is the deference between Epidemiology
and Clinical Medicine?
14
Components…
7. Application
16
History…
17
History…
18
Scope of Epidemiology
Originally, Epidemiology was concerned with
investigation & management of epidemics of
communicable diseases
How?
1. Elucidation of natural history of diseases
2.Description of health status of population
3. Establishing determinants of diseases
4. Evaluation of intervention effectiveness
20
Types of Epidemiology
Two major categories of Epidemiology
1.Descriptive Epidemiology
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Types…
2. Analytic Epidemiology
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Basic features of Epidemiology
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2. Communicable disease
Epidemiology
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Disease causation
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Theories of disease causality
27
Theories…
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Necessary Vs Sufficient
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Etiology of a disease
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Disease models
1.Epidemiological triangle
The interaction of an agent and host in an
appropriate environment results in disease
31
Disease models…
2. Web of causation
Complex interaction of factors results in disease
3. Wheel model
The hub (host) having a genetic make up as its core,
surrounded by an environment schematically divided
in to biological, physical and social
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Natural history of disease
33
Natural history…
35
Levels of disease…
2. Secondary prevention
36
Levels of disease…
3. Tertiary prevention
37
Infectious disease process
38
The agent
Possible outcomes of exposure to an infectious agent
39
The agent…
40
Reservoir Vs Carrier
Reservoir
An organism or habitat in which an infectious
agent normally lives, transforms, develops and/or
multiplies
Carrier
A person who doesn’t have apparent clinical
disease, but is a potential source of infection to
other people
41
Types of carriers
42
Types of carriers…
43
Importance of carriers
44
Effect of carriers on disease transmission
45
Modes of disease transmission
1.Direct transmission
Direct contact: physical contact with body part of
infected person: Touching, kissing,biting,sex
Example: HIV
Direct projection: projection of saliva droplets
while coughing, sneezing,spitting,talking,singing etc
Example: Common cold
Transplacental: Transmission from mother to fetus
through the placenta
Example: Syphilis
46
Modes of disease…
2. Indirect transmission
Vehicle-borne: transmission through
inanimate objects/non-living substances e.g
HIV by needles
48
Importance of mode of transmission
• A disease often has several modes of transmission
50
Conditions under which herd immunity
best functions
1. Single reservoir
2. Direct transmission
3. Total immunity
4. No carrier state
5. Uniform distribution of immunes
6. No overcrowding
53
Application of time periods
• Pre-patent period
– When should we investigate?
• Incubation period
– When was time of exposure?
• Communicable period
– When should we take care of infectiousness?
• Latent period
– When would relapse occur?
• Convalescent period
– When,after recovery an individual becomes non-infectious?
• Generation time
– When is the maximum risk for contacts?
54
Factors which influence the development of
disease
Strain of the agent
Dose of the agent
Route of infection
Host age, nutritional status, immune status
Influence of treatment
Influence of season
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3. Measures of disease
occurrence
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What are measures of disease occurrence?
57
How do we measure diseases?
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Descriptors
59
Descriptors
Proportions: a ratio in which the numerator is
included in the denominator
e.g proportion of TB cases in community A is 10%
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Which community is more affected?
61
When we call..
• When we call a measure a ratio, we mean a non-
proportional ratio
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Incidence rate
The proportion of a population that develops a
disease overtime
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Practical challenges in measuring incidence
rate
1. Identification of population at risk
Population at risk constitutes all those free of
the disease and susceptible to it
68
Prevalence rate
Two types
1. Point prevalence rate
2. Period prevalence rate
69
Point prevalence rate
Measures the proportion of a population with
a disease at a point in time
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Period prevalence rate
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Incidence Vs prevalence
Incidence rate considers only new cases of a disease
73
Mortality rates
These rates measures magnitude of deaths in a
community
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Common Mortality rates
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4. Measures of association
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2X2 table
Disease
No (+) c d c+d
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Totals
Marginal totals
a+b= Exposed
c+d= Non-exposed
a+c= Diseased
b+d= Non-diseased
Grand total
n = a+b+c+d
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Chi-square statistics
Chi-square tests whether there is an association
between two categorical variables
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Chi-Square…
Χ 2= Σ (O - E)2
E
O: Observed cells
E: Expected cells
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Relative risk (RR)
Expresses risk of developing a diseases in exposed
group (a + b) as compared to non-exposed group (c + d)
RR= a/(a+b)
c/(c+d)
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Interpretation of relative risk
High if RR>3
Moderate if RR is between 1.5 & 2.9
Weak if RR is between 1.2 & 1.4
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Odds ratio (OR)
Odds=P(E)/P(E’)=P(E)/(1-P(E))
86
Odds ratio…
Odds of exposure among Diseased=a/c
Odds of exposure among non-diseased=b/d
OR= (a/c)/(b/d)
OR= ad/bc (it is also called cross-product ratio)
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Attributable Risk (AR)
AR indicates how much of the risk is due to
/attributable/ to the exposure
90
Attributable risk percent (AR%)
91
Interpretation of AR%
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Population Attributable Risk (PAR)
93
Population attributable risk percent (PAR
%)
Estimates the proportion of disease in the study
population that is attributable to exposure and thus
could be eliminated if the exposure were eliminated
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Possible outcomes in studying the
relationship between exposure & disease
1. No association
RR=1
AR=0
2. Positive association
RR>1
AR>0
3. Negative association
RR<1 (fraction)
AR<0 (Negative)
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Risk Vs Preventive factors
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Association Vs Causation
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Possible explanations for observed
association
1. Chance
2. Bias
3. Confounding
4. Reverse causation
5. Reciprocal causation
6. Cause-effect relationship
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Accuracy of measurement
Internal validity:
Is the degree to which a measured value is true within
the sample
External validity:
Is the extent to which a measured value apply beyond
the sample
105
Test of statistical…
106
2. Estimation of confidence interval
107
Role of bias
Bias is any systematic error in the design, conduct or
analysis of an epidemiologic study that results in an
incorrect estimate of association between exposure
and disease
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Selection bias
Any systematic error that arises in the process of
identifying the study population
It affects the representativeness of the study
It occurs when there is a difference between sample
and population with respect to a variable
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Ways to minimize bias
111
Role of confounding
112
Effect of confounding
113
Control of confounding variables
During designing stage:
– Randomization
– Restriction
– Matching
115
Criteria to asses the strength…
1. Strength of association: The stronger the
association the more likely it is causal
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Study design
119
Types of Epidemiologic study designs
1. Descriptive studies
– Describe: who, when, where & how many
2. Analytic studies
– Analyse: How and why
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Types…
1. Observational studies
– The investigator observes nature
– No intervention
2. Intervention/Experimental studies
– Investigator intervenes
– He has a control over the situation
121
Types…
1. Prospective
– Conducted forward in time
2. Retrospective
– Conducted backward in time
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Types…
1. Qualitative studies
– Generate contextual data
– Also called exploratory studies
2. Quantitative studies
– Generate numerical data
– Also called explanatory studies
124
Types…
1. Community-based studies
– Conducted in communities
2. Institution-based studies
– Conducted in communities
3. Laboratory-based studies
– Conducted in major laboratories
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Types…
1. Cross-sectional studies
2. Case-control studies
3. Cohort studies
4. Experimental studies
126
Cross-sectional studies
In this study design information about the status of an
individual with respect to presence/absence of
exposure and diseased is assessed at a point in time.
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Cross-sectional…
129
Cross-sectional…
• Antecedent-consequence uncertainty
“Chicken or egg dilemma”
• Data dredging leading to inappropriate
comparison
• More vulnerable to bias
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Cross-sectional…
132
Case-control studies
133
Case-control…
Steps in conducting case-control studies
I. Define who is a case
– Establish strict diagnostic criteria
– All who fulfil the criteria will be “case population
– Those who don’t fulfil will be “control population”
II. Select a sample of cases from case population
– This sample must be representative of the case
population
134
Case-control…
Sources of cases
1. Hospitals (Health institution)
– Cost-less
– Bias-more
2. Population (Community)
– Cost-more
– Bias-less
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Case-control…
138
Case-control…
1. Retrospective case-control
– Uses prevalent cases
– Increased sample size
– Difficult to establish temporal sequence
– Useful for rare outcomes
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Case-control…
2. Prospective case-control
– Uses incident cases
– Establish temporal sequence
– Recall is not a serious problem
– Records are easily obtainable
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Case-control…
141
Case-control…
142
Case-control…
143
Cohort studies
1. Prospective (classical)
– Outcome hasn’t occurred at the beginning of the study
– It is the commonest and more reliable
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Cohort…
2. Retrospective (Historical)
145
Cohort…
1. Define exposure
2. Select exposed group
3. Select non-exposed group
4. Follow and collect data on outcome
5. Compare outcome b/n exposed & non-exposed
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Cohort…
147
Cohort…
148
Experimental studies
149
Experimental…
2. Preventive trials
– Conducted on healthy people
– To determine the effect of prevention on risk
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Experimental…
• Feasibility issues
– Getting adequate subjects
– Achieving satisfactory compliance
• Cost issues
– Experimental studies are expensive
153
Experimental…
– Randomization
– Blinding
– Placebo
154
Experimental…
156
Experimental…
157
7. Screening
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Screening
159
Aims of screening program
160
Criteria for selecting diseases for screening
161
Criteria for establishing screening program
162
Screening tests
Diagnostic test
D+ D-
Screening test T+ a b a+b
T- c d c+d
a+c b+d n
163
Definitions of cells
164
Definition of totals
165
Test performance
Validity of a test
166
Test performance
A. Sensitivity of a test
• The ability of a test to correctly identify those
who have the disease
• The probability that a diseased individual will
have a positive test result
• The proportion of people with a disease who
have a positive test result
• True positive rate (TPR)
167
Test performance
168
Test performance
B. Specificity of a test
• The ability of a test to correctly identify those who
don’t have the disease
• The probability that a disease-free individual will
have a negative test result
• The proportion of people without the disease who
have a negative test result
• True negative rate (TNR)
169
Test performance
170
Test performance
171
Test performance
Prevalence of a disease
The proportion of individuals with a disease
Prior/pre-test probability of a disease
Prevalence = P (D+)
= (a+c)/n
Yield of a test
Proportion of cases detected by the screening program
Yield = a/n
174
Multiple testing
Parallel testing:
– Tests are given concurrently
– At least one positive indicates disease
– Results in
• Greater sensitivity
• Increased PVN
• Decreased specificity
175
Multiple testing
Serial testing:
– Tests are administered sequentially
– All positive indicates disease
– Results in
• Lower sensitivity
• Increased specificity
• Increased PVP
176
Reliability of a test
– Internal reliability
• Internal consistency reliability
– External reliability
• Alternate test reliability
• Test-retest reliability
178
Evaluation of a screening program
179
In general
180
Thank you!
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